Opinion
CV-21-00389-TUC-JAS (MSA)
11-02-2022
Jamie Knight, Plaintiff, v. Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Honorable Maria S. Aguilera United States Magistrate Judge
Jamie Knight seeks judicial review of an unfavorable decision issued by the Commissioner of Social Security Administration (Commissioner). The matter has been fully briefed. (Docs. 21, 24, 25.) For the following reasons, the Court will recommend that the Commissioner's decision be affirmed.
Background
I. Procedural History
In 2020, Knight filed an application for disability insurance benefits, alleging a disability onset date of June 23, 2019. (AR 165.) The application was denied initially and on reconsideration. (AR 62, 72.) Knight requested a hearing before an administrative law judge (ALJ), and a hearing was held in February 2021. (AR 41-61, 109.) After the hearing, the ALJ issued a written decision denying Knight's application. (AR 13-22.) The Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. (AR 1-3.) Knight filed this lawsuit in September 2021. (Doc. 1.) ....
II. Plaintiff's Personal and Medical History
Knight is 56 years old. (See AR 165.) He has a high school education and briefly attended college. (AR 190.) He last worked as a mechanic. (AR 48, 55.) In 2017, he left that job to help renovate a relative's home so that it could be sold. (AR 48.)
Knight has been diagnosed with chronic obstructive pulmonary disease (COPD), lung nodules, and factor V Leiden. (AR 579.) He alleges his conditions cause shortness of breath on exertion, lightheadedness when he climbs stairs, and fatigue and weakness when he tries to carry weight. (AR 197.) As a result of his conditions, he says, he can do only very light physical activity (e.g., “mild yard work”). (AR 198.)
III. ALJ Decision
The ALJ followed the five-step sequential evaluation process for determining whether a claimant is disabled. 20 C.F.R. § 404.1520. At step one, the ALJ found that Knight had not engaged in substantial gainful activity since his alleged onset date. (AR 15.) At step two, the ALJ found that Knight had the following severe impairments: COPD with pulmonary nodules in the right lung, and moderately severe restrictive airway disease. (AR 15.) At step three, the ALJ found that Knight did not have an impairment or a combination of impairments that met or medically equaled the severity of a listed impairment. (AR 17.) Between steps three and four, the ALJ found that Knight had the residual functional capacity to perform light work with certain environmental restrictions. (AR 18.) At step four, the ALJ found that Knight could not perform his past relevant work. (AR 21.) At step five, the ALJ found that Knight could adjust to other work in the national economy. (AR 21.) The ALJ therefore concluded that Knight was not disabled. (AR 22.)
In denying Knight's application, the ALJ made much of the fact that Knight's disability period was only eight days in length (June 23, 2019, through June 30, 2019), and that there were virtually no medical records predating Knight's date last insured. (AR 16 (stating that treatment obtained on June 23, 2019, “appears to be essentially the only medical treatment and findings documented for the claimant before his date last insured of June 30, 2019”); AR 18 (stating that “there is almost no documentary medical evidence from before the claimant's date last insured of June 30, 2019”); AR 20 (stating that “there are almost no medical findings or specific limitations documented in the medical evidence before the date last insured of June 30, 2019”).) The ALJ believed that the scant medical evidence from before the date last insured did not support Knight's alleged limitations. (AR 16 (observing that on June 23, 2019, Knight “denied being short of breath” and had “no increased work of breathing”); AR 18 (remarking that “all the medical evidence objectively shows prior to [June 30, 2019,] is a report of constant, moderate cough for 4 days not associated with exercise” and “denial of shortness of breath”).) The ALJ believed that the medical evidence from after the date last insured also did not support Knight's alleged limitations. (AR 16 (observing that, in August 2019, Knight “denied a cough, shortness of breath, or wheeze” and that, in November 2019, his “respiratory symptoms had ‘significantly improved' except for some mild chest discomfort”).
Legal Standard
The ALJ's decision must be affirmed if it is supported by substantial evidence and free of legal error. Lambert v. Saul, 980 F.3d 1266, 1270 (9th Cir. 2020) (quoting Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008)). “Substantial evidence means more than a mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Coleman v. Saul, 979 F.3d 751, 755 (9th Cir. 2020) (quoting Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)). The ALJ's decision may not be overturned on account of an error that was “inconsequential to the ultimate nondisability determination.” Fordv. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020) (quoting Tommasetti, 533 F.3d at 1038).
Discussion
I. Evaluation of Symptom Testimony
Knight contends that the ALJ erred in discounting his symptom testimony. When, as here, the claimant's impairments could reasonably be expected to cause his alleged symptoms, and there is no evidence of malingering, the ALJ can reject the claimant's symptom testimony “only by offering specific, clear and convincing reasons for doing so.” Smith v. Kijakazi, 14 F.4th 1108, 1111-12 (9th Cir. 2021) (quoting Garrison v. Colvin, 759 F.3d 995, 1014-15 (9th Cir. 2014)). “This standard is ‘the most demanding required in Social Security cases.'” Id. at 1112 (quoting Moore v. Comm'r of Soc. Sec. Admin., 278 F.3d 920, 924 (9th Cir. 2002)).
In a March 2020 questionnaire, Knight reported that he experienced shortness of breath on exertion, lightheadedness when climbing stairs, and fatigue and weakness when trying to carry weight. (AR 197.) He also reported that he is unable to walk quickly or for long distances, and that he gets fatigued even when walking in a slow and controlled manner. (AR 197.) He reported that he can lift small, light objects up to ten pounds in weight, and that he is limited to “small chores” such as laundry and “mild yard work.” (AR 198.) He also reported that he needs breaks when performing chores and sometimes naps as well. (AR 198.) At his hearing in February 2021, Knight reported that he had started noticing shortness of breath in 2017. (AR 48.)
The ALJ offered three reasons for rejecting this testimony: it was inconsistent with the objective medical evidence; it was inconsistent with Knight's prior statements to his providers; and it was inconsistent with Knight's ability to perform yard work. (AR 18, 20.) In combination, the first and second reasons are clear and convincing.
A. Objective Medical Evidence
Objective medical evidence is a “useful” factor in evaluating the severity of a claimant's symptoms. 20 C.F.R. § 404.1529(c)(2). Here, the ALJ pointed to two pulmonary function tests indicating that Knight did not qualify for supplemental oxygen. (AR 306-07 (December 2019); AR 359 (February 2020).) She also pointed to records showing that Knight's lung nodules had decreased in size since they were discovered in September 2019. (AR 381 (February 2020); AR 559-60 (August 2020).) Finally, she pointed out that Knight's physical examinations mostly showed “grossly normal breathing.” (See, e.g., AR 548 (in October 2020, Knight's lungs were “clear throughout” on examination).) As discussed below, substantial evidence supports the ALJ's finding that Knight's testimony was inconsistent with the objective medical evidence.
The evidence indeed indicates that Knight had grossly normal breathing on examination-both before and after the date last insured. Thus, the ALJ could rationally find that such evidence undermined Knight's testimony about respiratory issues. (AR 336 (in April 2019, Knight's lungs were “clear to auscultation”); AR 255 (in June 2019, Knight's “lungs [were] clear to auscultation bilaterally with good air movement,” and he had “no increased work of breathing” and “no stridor, crackles, rubs, or wheezing”); AR 376 (in mid-July 2019, Knight had “breath sounds [that were] normal and good air movement,” and he had “no dyspnea, . . . wheezing, rales/crackles, or rhonchi”); AR 372 (in late July 2019, Knight's lungs were clear to auscultation bilaterally, and he had “normal chest expansion” and “no wheezing”); AR 269 (in August 2019, Knight had “no increased work of breathing”); AR 366 (in September 2019, after the nodules were discovered, Knight's lungs were “clear”); AR 319 (in October 2019, Knight's breathing was “even and regular”); AR 294 (in November 2019, Knight had “[g]ood air exchange bilaterally without any wheezes or rhonchi noted”); AR 552 (in February 2020, Knight's lungs were “clear”); AR 550 (in July 2020, Knight's lungs were “clear throughout” with “no wheezes or rhonchi”).) As for the chest scans, it plainly was reasonable for the ALJ to rely on the decreasing size of Knight's lung nodules, as he alleged that the nodules contributed to his respiratory issues.
With this context in mind, the ALJ could also rationally find that Knight's testimony was undermined by his pulmonary function tests. The tests indicated that although Knight's oxygen saturation dropped while he was walking, it did not drop so far as to qualify him for supplemental oxygen. (AR 359.) In addition, as the ALJ noted, although the provider who administered one of the tests remarked that Knight “likely” would qualify with “increase[d] activity,” the provider did not say “how much more activity” would be necessary, nor did he indicate whether Knight “would have been at that level of limitation prior to the date last insured.” (AR 18, 359.) Without that information, and in light of Knight's normal examination findings, the ALJ could reasonably find Knight's testimony inconsistent with the test results. Furthermore, one of the tests indicated that Knight had “good postbronchodilator improvement,” and Knight later indicated that his Albuterol (a bronchodilator) was “working well.” (AR 307, 548.)
In contending that the ALJ erred, Knight emphasizes that a computerized tomography (CT) scan performed in April 2021-nearly two years after the date last insured and about one month after the ALJ issued her decision-shows that he has “a new nodule” in his right lung. (AR 32.) Knight also complains about the ALJ's interpretation of the results of his pulmonary function tests. According to Knight, in context, the provider clearly would not agree that he could perform light work, and the ALJ erred by ignoring that context.
Knight's arguments are not persuasive. The new scan must be assessed in view of the entire record. As described above, before the date last insured and during the following months, Knight's physical examinations were grossly normal, and his existing lung nodules decreased in size. (And, as detailed in the next section, during the same period, Knight often denied respiratory issues.) The ALJ's analysis of this evidence is not undermined by a CT scan which is remote in time, and which fails to indicate how the new nodule relates to Knight's functioning during the relevant period. Similarly, the ALJ's evaluation of the test results was reasonable in view of the whole record. Knight has not shown error merely by offering a different interpretation of the evidence. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005) (“Where evidence is susceptible to more than one rational interpretation, it is the ALJ's conclusion that must be upheld.”).
B. Inconsistent Statements
An ALJ may discount symptom testimony if it is inconsistent with other statements the claimant has made about his symptoms. Popa v. Berryhill, 872 F.3d 901, 906 (9th Cir. 2017) (citing Tonapetyan v. Halter, 242 F.3d 1144, 1148 (9th Cir. 2001)). Here, the ALJ relied on the fact that, “more often than not,” Knight “denied cough, denied shortness of breath, and denied wheeze” at his medical appointments. (AR 20.) As discussed below, substantial evidence supports the ALJ's finding that these reports were inconsistent with Knight's testimony.
The record confirms that Knight mostly denied respiratory symptoms. This is true of the months preceding the alleged onset date. (AR 476 (in April 2019, Knight denied “shortness of breath” and “cough”); AR 378 (in May 2019, Knight denied “dyspnea, wheezing, cough, [and] shortness of breath,” as well as “dyspnea during exertion”).) It is true of the disability period. (AR 254 (in June 2019, Knight reported a cough that was “moderate” in severity but denied “congestion, shortness of breath, [and] wheeze”).)
It is also true of the remainder of 2019. (AR 372 (in July 2019, Knight reported a recent fainting episode but denied “any exertional symptoms” and “shortness of breath”); AR 268 (in August 2019, Knight denied “congestion, cough, shortness of breath, [and] wheeze”); AR 366 (in September 2019, on the day Knight's lung nodules were discovered, Knight denied “dyspnea, wheezing, cough, shortness of breath, or pain on deep breath,” as well as “dyspnea during exertion”); AR 557 (in October 2019, Knight reported feeling like “his lungs won't fully expand, as if he can't get a good deep breath,” but also stated that it was “out of the ordinary for him to be having problems breathing upon activity”); AR 292 (in November 2019, a few weeks after reporting increasing shortness of breath, Knight reported that his symptoms had “significantly improved except for some mild chest discomfort”).) Even in 2020, Knight at times reported only mild respiratory issues. (AR 552 (in February 2020, Knight reported “get[ting] winded easily but recovering within 2 minutes”); AR 550 (in July 2020, Knight reported “doing well” and “doing some physical work without dyspnea being noted”).)
Knight frequently denied respiratory issues-even during exertion-before, during, and after the disability period. The ALJ could rationally conclude that those reports were inconsistent with Knight's testimony that he had been experiencing respiratory symptoms since before the alleged onset date.
C. Daily Activities
An ALJ may discount a claimant's symptom testimony if his daily activities either (a) contradict the testimony or (b) involve skills that could be transferred to the workplace. Orn v. Astrue, 495 F.3d 625, 639 (9th Cir. 2007). Here, the ALJ noted that Knight was “not bedridden, as his activities of daily living are reported to include doing yard work.” (AR 18.) As an initial matter, the notion that Knight must be bedridden to be disabled is incorrect. See Magallanes v. Bowen, 881 F.2d 747, 756 (9th Cir. 1989) (stating that a claimant need not “vegetate in a dark room” (quoting Cooper v. Bowen, 815 F.2d 557, 561 (9th Cir. 1987))). Moving on, substantial evidence does not support the ALJ's reliance on Knight's ability to do yard work. The ALJ did not meaningfully analyze whether that activity contradicted his symptom testimony; she simply noted that he engaged in such activity. Furthermore, it is not clear whether there is a contradiction, as Knight reported that he did only “mild yard work” with breaks for recovery.
Although substantial evidence does not support this part of the ALJ's decision, inconsistencies with the objective medical evidence and with Knight's self-reports, in combination, constitute clear and convincing reasons for discounting Knight's testimony. The Court rejects Knight's claim of error.
II. Evaluation of Medical Opinion
Knight contends that the ALJ erred in evaluating the opinion of his physician, Dr. Guy Crawford. In November 2020, on a fill-in form created by Knight's counsel, Dr. Crawford indicated that Knight's symptoms included “possible” shortness of breath on exertion, deep vein thrombosis after sitting for too long, and phlegm. (AR 579.) Dr. Crawford opined that these symptoms would “occasionally” interfere with Knight's attention and concentration. (AR 579.) He also opined that, in an eight-hour workday, Knight could sit for a total of two hours, stand or walk for a total of two hours, and occasionally lift up to 20 pounds. (AR 579.) Finally, he opined that Knight would need to shift positions every two hours, need extra breaks depending on the work, and miss at least four days of work per month. (AR 579-80.)
ALJs must determine the persuasiveness of each medical opinion based on the factors of “supportability” and “consistency.” 20 C.F.R. § 404.1520c(b)(2). An opinion that is well-supported by objective medical evidence and explanation is more persuasive, as is an opinion that is consistent with evidence from other medical and nonmedical sources. Id. § 404.1520c(c)(1)-(2). Here, the ALJ found that the medical evidence supported Dr. Crawford's opinion that Knight could occasionally lift 20 pounds. (AR 19.) The ALJ rejected the remainder of Dr. Crawford's opinions as “very unpersuasive and unconvincing.” (AR 19.) This determination is supported by substantial evidence.
The ALJ offered at least two reasons for why the supportability factor cut against Dr. Crawford's opinions. First, the ALJ noted the lack of a supporting explanation for the opinion. (AR 19 (“Importantly, there was no effort made to correlate these limitations in any way with specific laboratory or examination findings.”).) An ALJ may not reject a checkbox opinion for lack of a supporting explanation if an explanation can be found in the physician's treatment notes. Garrison v. Colvin, 759 F.3d 995, 1014 n.17 (9th Cir. 2014). Here, though, no supporting explanation is apparent in Dr. Crawford's notes. During his few appointments with Dr. Crawford, Knight had no dyspnea or shortness of breath, and his lungs were clear to auscultation. (See AR 375-76 (in July 2019, Knight reported shortness of breath at 8,000 feet in elevation, but he had no shortness of breath, dyspnea, or wheezing on that day, and his “breath sounds [were] normal [with] good air movement”); AR 365-66 (in September 2019, a few weeks after reporting “a persistent cough and [shortness of breath],” Knight had “no dyspnea, wheezing, cough, shortness of breath” and “no . . . dyspnea during exertion”); AR 583-84 (in November 2020-on the date of Dr. Crawford's opinion-Knight had no shortness of breath, dyspnea, or wheezing, and his “breath sounds [were] normal [with] good air movement”).) The ALJ could rationally conclude that these records, which largely describe unremarkable findings, did not justify the extreme restrictions proposed by Dr. Crawford.
In challenging the ALJ's analysis, Knight theorizes that Dr. Crawford was aware of other physicians' treatment notes and based his opinion on those other notes. However, he points to nothing in the record requiring that conclusion. Moreover, the treatment notes consistently describe normal findings. Thus, the Court declines to find error on this basis.
Second, and relatedly, the ALJ noted that Dr. Crawford failed to “indicate an onset date when the[] assessed limitations would have first been applicable,” such that there was “no assurance . . . that Dr. Crawford . . . would have extended the[] same assessed limitations back to the date last insured.” (AR 17.) The ALJ believed this was “a crucial error considering that the claimant's date last insured was 16 months earlier” than the date of the opinion. (AR 19.) In general, observations and opinions made after the date last insured are relevant to the claimant's condition during the disability period. Smith v. Bowen, 849 F.2d 1222, 1225 (9th Cir. 1988) (citing Kemp v. Weinberger, 522 F.2d 967, 969 (9th Cir. 1975) (per curiam)). Even so, an ALJ may properly reject an opinion on the ground that it is far removed in time from the relevant period and does not clearly address that period. Lombardo v. Schweiker, 749 F.2d 565, 567 (9th Cir. 1984) (per curiam) (affirming the ALJ's rejection of an opinion rendered one-and-a-half years after the date last insured). Here, Dr. Crawford did not indicate whether the restrictions Knight allegedly had in November 2020 also existed in June 2019. The ALJ could rationally rely on this omission to reject Dr. Crawford's opinion. See Schalk v. Berryhill, 734 Fed.Appx. 475, 478 (9th Cir. 2018) (upholding the rejection of an opinion in part because the doctor's “examination and opinion occurred fifteen months after the date last insured and she did not indicate how the[] limitations would have applied in the past”). This is especially true considering that, immediately before and after the date last insured, Knight mostly denied respiratory issues, and no severe issues were evident from his physical examinations.
Knight argues that the ALJ erred in failing to ask Dr. Crawford if he would have extended the proposed work restrictions to the date last insured. See Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996) (holding the ALJ erred in failing to subpoena, or submit questions to, a physician regarding the basis for his opinion). Given the state of the record, the Court doubts that the duty to investigate was triggered. See McLeodv. Astrue, 640 F.3d 881, 885 (9th Cir. 2011) (stating the duty is triggered “where the record establishes ambiguity or inadequacy”). Even if it were, though, the ALJ's error would be harmless, since the ALJ separately relied on the lack of evidence supporting Dr. Crawford's opinion.
As for the inconsistency factor, the ALJ found that Dr. Crawford's opinions were inconsistent with “physical examinations throughout the record,” which, “more often than not,” showed that Knight “demonstrated no cough, shortness of breath, and no wheeze.” (AR 19.) As detailed at length in this report, this is an accurate representation of the record. Before, during, and after the disability period, physical examinations of Knight's respiratory condition were mostly unremarkable. Knight also frequently denied respiratory issues. The ALJ could rationally conclude that “[t]he assessed limitations . . . therefore appear extreme” in comparison to that evidence. (AR 19.)
The ALJ reasonably determined that Dr. Crawford's opinion lacked supporting evidence and explanation and was inconsistent with other evidence in the record. See 20 C.F.R. § 404.1520c(b)(2) (stating that supportability and consistency are “the most important factors” when evaluating a medical opinion). Therefore, the Court rejects Knight's claim of error.
IT IS RECOMMENDED that the Commissioner's decision be affirmed.
This recommendation is not immediately appealable to the United States Court of Appeals for the Ninth Circuit. The parties shall have fourteen days from the date of service of this recommendation to file specific written objections with the district court. The parties shall have fourteen days to file responses to any objections. Fed.R.Civ.P. 72(b)(2). No replies may be filed absent prior authorization by the district court. Failure to file timely objections may result in the acceptance of this recommendation without de novo review. United States v. Reyna-Tapia, 328 F.3d 1114, 1121 (9th Cir. 2003) (en banc).
The Clerk of Court is directed to terminate the referral of this matter. Filed objections should bear the following case number: CV-21-00389-TUC-JAS.